Participation by Clients and Nurse Midwives in Family Planning Decision Making in Indonesia

The purpose of this study was to improve understanding on the quality of decision making during family planning (FP) consultations in developing countries. This study examines decision-making practice during FP consultations in Indonesia by rating client conduct and provider performance. Results show that FP clients make a significant contribution to the quality of the decision-making process, most notably by identifying the problem requiring a decision, expressing their feelings about using a method, and asking questions.



Background

The authors note that the choice of a family planning method depends largely on the client’s personal circumstances, preferences, and priorities rather than on medical factors. The choice of a method is based mainly on convenience and side effects. The study uses data from a larger study in support of the National Family Planning Coordinating Board
(BKKBN) – an Indonesian initiative to improve the overall quality of reproductive health care. This article also serves as a further test of the OPTION assessment tool and its applicability.

Methodology

This article re-analyses audiotapes gathered by one recent BKKBN study to examine the decision-making process. The specific research questions for this study are:

1. What types of decisions do new and continuing family planning clients make?
2. What are providers’ strengths and weaknesses in family planning decision-making?
3. How much do clients contribute to each step in the decision-making process?

The present study analyses a subset of data from a larger study conducted in two districts of East Java province, Jombang and Mojokerto, and includes a total sample size of n = 179 separate client sessions. Two types of analysis were conducted: (1) a qualitative content analysis to identify communication behaviours that enhance or hinder decision making, and (2) a quantitative analysis of the quality of decision making, which rated multiple specific behaviours, each on a 5-point scale. This newly developed tool assesses both client and provider performance and rates them on a set of mirror behaviours.

The tool includes 14 key decision-making behaviours for new client consultations, and 12 behaviours for continuing client consultations. Each behaviour was rated on a 5-point scale with the midpoint (3) as the minimum acceptable level of performance, based on Indonesian family planning programme expectations. Substandard performance was rated either as 1 (for non-existent behaviours) or 2 (poor performance) while above standard performance was rated as 4 or 5. The results reported herein are as a percentage of sessions that met minimum standards (3 or greater), though mean ratings are reported in the tables in the article. Sessions were also rated for one other item: whether the client, provider, or both took responsibility for making the decision about contraceptive method.

Results

A differentiation is made between new and continuing clients because of the potential differences in their interests and decision-making opportunities. While new clients have clearly arrived to begin use of a contraceptive, and thus make a choice about which method, continuing clients may have merely been in for refills (and unlikely to consider a change in method) or, they may have arrived seeking a remedy for side effects. In the second scenario, clients may have substantial opportunity for a choice to change methods.

42% of the women included in this study were new clients, those not currently using a contraceptive, though 60% had previously used FP and thus already had a method in mind. The other two-fifths of new clients had never used contraception before although most (93%) also had a method in mind. 58% percent of the women in the study were continuing clients, and current users of contraceptives. Of these, 87% had some concern about their method that they wanted to discuss with the provider. Contraceptive dissatisfaction generally centred on conditions they believed to be side effects, such as irregular menstruation, vaginal discharge, pain, weight gain, and black freckles on the face. These women must choose whether to continue without remedy, to take medication (if available) to counter side effects, or to switch methods.

Clients made important contributions to the decision-making process, often substituting for provider weaknesses. Client contributions exceeded provider performance in three of the 12 or 14 areas:

• Identifying the problem requiring a decision (29% versus 7% of new client sessions, 49% versus 15% of continuing client sessions);
• Asking or eliciting client questions (34% versus 16% of new client sessions, 50% versus 23% of continuing client sessions); and,
• Expressing or eliciting client feelings about a method (24% versus 7% of new client sessions, 29% versus 17% of continuing client sessions).

Clients were also predominant in final decisions about the choice of methods:

• Three-quarters of new clients clearly expressed their desire for a certain method and in 96% of new client consultations clients were solely or largely responsible for selecting a method.
• In 74% of continuing client consultations, clients were solely or largely responsible for choosing a course of action.
• The consultations generally seem to follow the informed choice model.

The performance of providers was generally weak during the initial part of the decision-making process. Only in 0–15% of consultations did providers perform adequately in: identifying a problem requiring a decision, explaining that clients can choose among different alternatives, and discussing the importance of client participation. Provider performance was stronger in the middle portion of the decision-making process, involving client probing and information exchange. Patterns were different based on whether the client was new, in which providers were strongest in determining if the client had a method in mind (81%) and in mentioning more than one family planning method (69%), versus consultations with continuing clients, in which providers were most likely to do an adequate job of probing for changes in the client’s situation (48%) and tailoring information to that situation (63%). However, providers rarely investigated clients’ dissatisfaction with their method (17%) or mentioned more than one course of remedial action (25%).

Conclusion

There were several specific client and provider behaviours that facilitated better client decision-making and which should be encouraged/reinforced.

• Client behaviours: clear communication by clients, self-disclosure by clients with regards to doubts and concerns, and the use of pointed questions.
• Provider behaviours: sensitivity to the client’s situation and attitudes by inquiring about client’s reproductive intentions, breastfeeding status, and prior use of family planning and recognizing and responding to client concerns.

While the principal of informed choice has definitely permeated family planning activities it was also noted that it was applied more weakly in sessions with continuing clients. Provider performance is weak; more so with regards to interpersonal skills than technical skills as providers typically dismiss client concerns, often offering reassurance but no genuine alternatives. There is an apparent need for changes in training content and supervision criteria to improve weak provider skills, but it also suggests that clients are decisive in consultations and that there needs to be further encouragement of client assertiveness.